Provider Demographics
NPI:1619152402
Name:PACIFIC COAST PEDIATRIC CENTER INC
Entity Type:Organization
Organization Name:PACIFIC COAST PEDIATRIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PARTNER, SECY-TREAS
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-722-0272
Mailing Address - Street 1:252 GREEN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3138
Mailing Address - Country:US
Mailing Address - Phone:831-722-0272
Mailing Address - Fax:831-722-1007
Practice Address - Street 1:252 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3138
Practice Address - Country:US
Practice Address - Phone:831-722-0272
Practice Address - Fax:831-722-1007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-31
Last Update Date:2008-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36791OtherFICTITIOUS NAME PERMIT CA